|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$17,544.80
|
|
|
Service Code
|
MSDRG 639
|
| Min. Negotiated Rate |
$5,264.05 |
| Max. Negotiated Rate |
$17,544.80 |
| Rate for Payer: United Healthcare PPO |
$9,828.18
|
| Rate for Payer: Aetna Managed Medicare |
$5,264.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,554.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,389.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,870.32
|
| Rate for Payer: Anthem Medicare Advantage |
$5,264.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,264.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,264.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,264.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,956.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,264.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,624.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,264.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,264.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,264.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,264.05
|
| Rate for Payer: NAPHCARE Commercial |
$7,896.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,264.05
|
| Rate for Payer: The Alliance Commercial |
$17,544.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,264.05
|
| Rate for Payer: Wellcare Medicare |
$5,264.05
|
|
|
DIABETES WITHOUT COMPLICATIONS
|
Facility
|
OP
|
$25.46
|
|
|
Service Code
|
EAPG 00713
|
| Min. Negotiated Rate |
$24.48 |
| Max. Negotiated Rate |
$25.46 |
| Rate for Payer: Anthem Medicaid |
$24.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$24.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.48
|
| Rate for Payer: Dean Health Medicaid |
$24.48
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24.48
|
| Rate for Payer: Managed Health Services Medicaid |
$25.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24.48
|
| Rate for Payer: United Healthcare Medicaid |
$24.48
|
|
|
DIABETES WITH RENAL MANIFESTATIONS
|
Facility
|
OP
|
$28.24
|
|
|
Service Code
|
EAPG 00714
|
| Min. Negotiated Rate |
$27.15 |
| Max. Negotiated Rate |
$28.24 |
| Rate for Payer: Anthem Medicaid |
$27.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.15
|
| Rate for Payer: Dean Health Medicaid |
$27.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.15
|
| Rate for Payer: Managed Health Services Medicaid |
$28.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.15
|
| Rate for Payer: United Healthcare Medicaid |
$27.15
|
|
|
DIABETES WITH VASCULAR COMPLICATIONS INCLUDING FOOT AND OTHER SKIN ULCERS
|
Facility
|
OP
|
$28.37
|
|
|
Service Code
|
EAPG 00715
|
| Min. Negotiated Rate |
$27.28 |
| Max. Negotiated Rate |
$28.37 |
| Rate for Payer: Anthem Medicaid |
$27.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.28
|
| Rate for Payer: Dean Health Medicaid |
$27.28
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.28
|
| Rate for Payer: Managed Health Services Medicaid |
$28.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.28
|
| Rate for Payer: United Healthcare Medicaid |
$27.28
|
|
|
Diabetic Outpatient Class (30 Min) G0109
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
3144169
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$54.53 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna Commercial |
$100.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.98
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$102.38
|
| Rate for Payer: Health EOS Commercial |
$99.04
|
| Rate for Payer: HFN Commercial |
$102.38
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: Preferred Network Access Commercial |
$102.38
|
| Rate for Payer: Quartz Beloit One Network |
$54.53
|
| Rate for Payer: Quartz Commercial |
$66.77
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Diabetic Outpatient Class (30 Min) G0109
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
3144169
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$31.16 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna Commercial |
$100.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Aetna Managed Medicare |
$31.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.98
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$102.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.27
|
| Rate for Payer: Health EOS Commercial |
$99.04
|
| Rate for Payer: HFN Commercial |
$102.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.46
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: NAPHCARE Commercial |
$66.77
|
| Rate for Payer: Preferred Network Access Commercial |
$102.38
|
| Rate for Payer: Quartz Beloit One Network |
$54.53
|
| Rate for Payer: Quartz Commercial |
$72.33
|
| Rate for Payer: Quartz Medicare Advantage |
$66.77
|
| Rate for Payer: The Alliance Commercial |
$64.44
|
| Rate for Payer: United Healthcare PPO |
$83.46
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Diabetic Outpatient Therapy (30 Min) G0108
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
3144168
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$57.95 |
| Max. Negotiated Rate |
$223.93 |
| Rate for Payer: Aetna Commercial |
$186.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Aetna Managed Medicare |
$57.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$134.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$103.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.69
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.82
|
| Rate for Payer: Health EOS Commercial |
$184.19
|
| Rate for Payer: HFN Commercial |
$190.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.22
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: NAPHCARE Commercial |
$124.18
|
| Rate for Payer: Preferred Network Access Commercial |
$190.40
|
| Rate for Payer: Quartz Beloit One Network |
$101.41
|
| Rate for Payer: Quartz Commercial |
$134.52
|
| Rate for Payer: Quartz Medicare Advantage |
$124.18
|
| Rate for Payer: The Alliance Commercial |
$223.93
|
| Rate for Payer: United Healthcare PPO |
$155.22
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: WPS Commercial |
$153.29
|
|
|
Diabetic Outpatient Therapy (30 Min) G0108
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
3144168
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$101.41 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: Aetna Commercial |
$186.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.69
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Health EOS Commercial |
$184.19
|
| Rate for Payer: HFN Commercial |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: Preferred Network Access Commercial |
$190.40
|
| Rate for Payer: Quartz Beloit One Network |
$101.41
|
| Rate for Payer: Quartz Commercial |
$124.18
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: WPS Commercial |
$153.29
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$35.69 |
| Max. Negotiated Rate |
$135.88 |
| Rate for Payer: Aetna Commercial |
$77.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$47.62
|
| Rate for Payer: Anthem Medicare Advantage |
$47.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.62
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$77.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.62
|
| Rate for Payer: Health EOS Commercial |
$73.82
|
| Rate for Payer: HFN Commercial |
$77.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.62
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$71.43
|
| Rate for Payer: Preferred Network Access Commercial |
$77.06
|
| Rate for Payer: Quartz Beloit One Network |
$35.69
|
| Rate for Payer: Quartz Commercial |
$46.24
|
| Rate for Payer: Quartz Medicare Advantage |
$47.62
|
| Rate for Payer: The Alliance Commercial |
$130.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.62
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$83.34
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.71 |
| Max. Negotiated Rate |
$190.49 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$22.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.40
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.84
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$48.67
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$52.73
|
| Rate for Payer: Quartz Medicare Advantage |
$48.67
|
| Rate for Payer: The Alliance Commercial |
$190.49
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
Diab Manage Trn Per Indiv G0108
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
5454715
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.08 |
| Max. Negotiated Rate |
$196.81 |
| Rate for Payer: Aetna Commercial |
$114.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$55.98
|
| Rate for Payer: Anthem Medicare Advantage |
$55.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$55.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$55.98
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$114.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.98
|
| Rate for Payer: Health EOS Commercial |
$109.78
|
| Rate for Payer: HFN Commercial |
$114.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$55.98
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$83.97
|
| Rate for Payer: Preferred Network Access Commercial |
$114.61
|
| Rate for Payer: Quartz Beloit One Network |
$53.08
|
| Rate for Payer: Quartz Commercial |
$68.76
|
| Rate for Payer: Quartz Medicare Advantage |
$55.98
|
| Rate for Payer: The Alliance Commercial |
$153.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55.98
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$97.97
|
|
|
Diab shoe for density insert A5500
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
Diab shoe for density insert A5500
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$271.74 |
| Rate for Payer: Aetna Commercial |
$96.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$94.26
|
| Rate for Payer: Anthem Medicare Advantage |
$94.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$94.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$94.26
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$96.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.26
|
| Rate for Payer: Health EOS Commercial |
$92.75
|
| Rate for Payer: HFN Commercial |
$96.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$94.26
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$141.38
|
| Rate for Payer: Preferred Network Access Commercial |
$96.82
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$58.09
|
| Rate for Payer: Quartz Medicare Advantage |
$94.26
|
| Rate for Payer: The Alliance Commercial |
$259.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.26
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$164.95
|
|
|
Diab shoe for density insert A5500
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$377.02 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$377.02
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
Diagnostic - Bronchoscopy Charge
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
2990189
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,124.01 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,600.83
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
Diagnostic - Bronchoscopy Charge
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
2990189
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,873.14 |
| Max. Negotiated Rate |
$6,968.10 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,873.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1,873.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,873.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,873.14
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,873.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,873.14
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,968.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,873.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,873.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,873.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,873.14
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,809.72
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,817.57
|
| Rate for Payer: Quartz Medicare Advantage |
$1,873.14
|
| Rate for Payer: The Alliance Commercial |
$3,184.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,873.14
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: Wellcare Medicare |
$1,873.14
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
DIAGNOSTIC CARDIAC CATHETERIZATION
|
Facility
|
OP
|
$533.72
|
|
|
Service Code
|
EAPG 00084
|
| Min. Negotiated Rate |
$513.20 |
| Max. Negotiated Rate |
$533.72 |
| Rate for Payer: Anthem Medicaid |
$513.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$513.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$513.20
|
| Rate for Payer: Dean Health Medicaid |
$513.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$513.20
|
| Rate for Payer: Managed Health Services Medicaid |
$533.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$513.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$513.20
|
| Rate for Payer: United Healthcare Medicaid |
$513.20
|
|
|
DIAGNOSTIC COLONOSCOPY 45378
|
Professional
|
Both
|
$2,188.00
|
|
|
Service Code
|
CPT 45378
|
| Hospital Charge Code |
3014805
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$159.44 |
| Max. Negotiated Rate |
$2,161.74 |
| Rate for Payer: Aetna Commercial |
$2,161.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,956.95
|
| Rate for Payer: Aetna Managed Medicare |
$159.44
|
| Rate for Payer: Anthem Medicare Advantage |
$159.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$159.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$159.44
|
| Rate for Payer: Cash Price |
$656.40
|
| Rate for Payer: Cash Price |
$656.40
|
| Rate for Payer: Cash Price |
$656.40
|
| Rate for Payer: Cigna Commercial |
$2,161.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$358.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.44
|
| Rate for Payer: Health EOS Commercial |
$2,070.72
|
| Rate for Payer: HFN Commercial |
$2,161.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$641.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$641.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$159.44
|
| Rate for Payer: Multiplan Commercial |
$1,820.42
|
| Rate for Payer: NAPHCARE Commercial |
$239.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,161.74
|
| Rate for Payer: Quartz Beloit One Network |
$1,001.23
|
| Rate for Payer: Quartz Commercial |
$1,297.05
|
| Rate for Payer: Quartz Medicare Advantage |
$159.44
|
| Rate for Payer: The Alliance Commercial |
$677.63
|
| Rate for Payer: United Healthcare Medicaid |
$358.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$159.44
|
| Rate for Payer: WEA Trust Commercial |
$1,251.54
|
| Rate for Payer: WPS Commercial |
$717.49
|
|
|
DIAGNOSTIC COLONOSCOPY, EXTENDED 4537822
|
Professional
|
Both
|
$2,626.00
|
|
|
Service Code
|
CPT 45378 22
|
| Hospital Charge Code |
6178511
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$358.58 |
| Max. Negotiated Rate |
$2,594.49 |
| Rate for Payer: Aetna Commercial |
$2,594.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,348.69
|
| Rate for Payer: Cash Price |
$787.80
|
| Rate for Payer: Cash Price |
$787.80
|
| Rate for Payer: Cash Price |
$787.80
|
| Rate for Payer: Cigna Commercial |
$2,594.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$358.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,638.62
|
| Rate for Payer: Health EOS Commercial |
$2,485.25
|
| Rate for Payer: HFN Commercial |
$2,594.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$641.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$641.91
|
| Rate for Payer: Multiplan Commercial |
$2,184.83
|
| Rate for Payer: Preferred Network Access Commercial |
$2,594.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,201.66
|
| Rate for Payer: Quartz Commercial |
$1,556.69
|
| Rate for Payer: The Alliance Commercial |
$1,365.52
|
| Rate for Payer: United Healthcare Medicaid |
$358.58
|
| Rate for Payer: WEA Trust Commercial |
$1,502.07
|
| Rate for Payer: WPS Commercial |
$2,022.81
|
|
|
DIAGNOSTIC DENTAL PROCEDURES
|
Facility
|
OP
|
$27.91
|
|
|
Service Code
|
EAPG 00376
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$27.91 |
| Rate for Payer: Anthem Medicaid |
$26.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$26.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.84
|
| Rate for Payer: Dean Health Medicaid |
$26.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.84
|
| Rate for Payer: Managed Health Services Medicaid |
$27.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.84
|
| Rate for Payer: United Healthcare Medicaid |
$26.84
|
|
|
Diagnostic Evaluation (No Medical) 90791
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
CPT 90791
|
| Hospital Charge Code |
2990616
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$141.92 |
| Max. Negotiated Rate |
$567.67 |
| Rate for Payer: Aetna Commercial |
$553.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$500.86
|
| Rate for Payer: Aetna Managed Medicare |
$141.92
|
| Rate for Payer: Anthem Medicare Advantage |
$141.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$141.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$141.92
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$553.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$291.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.92
|
| Rate for Payer: Health EOS Commercial |
$529.98
|
| Rate for Payer: HFN Commercial |
$553.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$557.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$557.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$141.92
|
| Rate for Payer: Multiplan Commercial |
$465.92
|
| Rate for Payer: NAPHCARE Commercial |
$212.88
|
| Rate for Payer: Preferred Network Access Commercial |
$553.28
|
| Rate for Payer: Quartz Beloit One Network |
$256.26
|
| Rate for Payer: Quartz Commercial |
$331.97
|
| Rate for Payer: Quartz Medicare Advantage |
$141.92
|
| Rate for Payer: The Alliance Commercial |
$354.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.92
|
| Rate for Payer: WEA Trust Commercial |
$320.32
|
| Rate for Payer: WPS Commercial |
$567.67
|
|
|
Diagnostic OAE
|
Professional
|
Both
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
3203489
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$33.97 |
| Max. Negotiated Rate |
$525.62 |
| Rate for Payer: Aetna Commercial |
$525.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Aetna Managed Medicare |
$33.97
|
| Rate for Payer: Anthem Medicare Advantage |
$33.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.97
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$525.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.97
|
| Rate for Payer: Health EOS Commercial |
$503.48
|
| Rate for Payer: HFN Commercial |
$525.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.97
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: NAPHCARE Commercial |
$50.95
|
| Rate for Payer: Preferred Network Access Commercial |
$525.62
|
| Rate for Payer: Quartz Beloit One Network |
$243.44
|
| Rate for Payer: Quartz Commercial |
$315.37
|
| Rate for Payer: Quartz Medicare Advantage |
$33.97
|
| Rate for Payer: The Alliance Commercial |
$84.92
|
| Rate for Payer: United Healthcare Medicaid |
$81.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.97
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$135.87
|
|
|
Diagnostic OAE
|
Facility
|
IP
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
3203489
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$271.11 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$331.97
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
Diagnostic OAE
|
Facility
|
OP
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
3203489
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$265.57 |
| Max. Negotiated Rate |
$1,570.82 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Aetna Managed Medicare |
$392.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.57
|
| Rate for Payer: Anthem Medicare Advantage |
$392.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$392.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$392.70
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$392.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$392.70
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,460.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$392.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$392.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$392.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$392.70
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: NAPHCARE Commercial |
$589.06
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$359.63
|
| Rate for Payer: Quartz Medicare Advantage |
$392.70
|
| Rate for Payer: The Alliance Commercial |
$1,570.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$392.70
|
| Rate for Payer: United Healthcare PPO |
$414.96
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: Wellcare Medicare |
$392.70
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
